Provider Demographics
NPI:1427234970
Name:LAKE OZARK FAMILY EYECARE, INC.
Entity type:Organization
Organization Name:LAKE OZARK FAMILY EYECARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EVELAND
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:573-365-3717
Mailing Address - Street 1:PO BOX 2347
Mailing Address - Street 2:
Mailing Address - City:LAKE OZARK
Mailing Address - State:MO
Mailing Address - Zip Code:65049-2347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3251 BAGNELL DAM BLVD
Practice Address - Street 2:
Practice Address - City:LAKE OZARK
Practice Address - State:MO
Practice Address - Zip Code:65049-9745
Practice Address - Country:US
Practice Address - Phone:573-365-3717
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-15
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO3452152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO000015717Medicare PIN
MODN4170Medicare PIN
MO6183320001Medicare NSC